| NPI | 1518569961 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-166439) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NE 2520) |
| 363A00000X Physician Assistant (Licence: ID 7071299) | |
| Enumeration Date | 2020-11-11 |
| Last Update Date | 2026-02-18 |