| NPI | 1548843840 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-14174) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA063364) |
| Enumeration Date | 2021-05-04 |
| Last Update Date | 2025-08-26 |