| NPI | 1386342798 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2024009541) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 5421) |
| Enumeration Date | 2023-02-16 |
| Last Update Date | 2025-04-01 |