| NPI | 1508756420 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OA007314) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA066756) |
| Enumeration Date | 2025-07-03 |
| Last Update Date | 2025-07-03 |