| NPI | 1457762106 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA4966) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: HI AMD-875) |
| 363AM0700X Physician Assistant, Medical (Licence: MA PA4966) | |
| Enumeration Date | 2014-05-15 |
| Last Update Date | 2025-03-10 |