| NPI | 1477008860 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA5798) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 10704) |
| Enumeration Date | 2016-08-16 |
| Last Update Date | 2025-02-10 |