| NPI | 1417583709 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 9730) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 6152) |
| Enumeration Date | 2020-03-18 |
| Last Update Date | 2025-12-09 |