| NPI | 1417543455 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 4387) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VA 0110007581) |
| Enumeration Date | 2020-12-14 |
| Last Update Date | 2025-02-11 |