| NPI | 1538820642 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110012076) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2500092248) |
| Enumeration Date | 2022-01-02 |
| Last Update Date | 2026-07-07 |