| NPI | 1457389363 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 900) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 1005182) |
| Enumeration Date | 2006-06-29 |
| Last Update Date | 2025-06-10 |