| NPI | 1568149920 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 5OPXW2) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL 2361) |
| Enumeration Date | 2023-06-28 |
| Last Update Date | 2026-06-16 |