| NPI | 1528588092 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-16548) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110-005811) |
| 363A00000X Physician Assistant (Licence: CA 60075) | |
| Enumeration Date | 2017-06-26 |
| Last Update Date | 2026-08-20 |