| NPI | 1578024105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0008707) |
| Enumeration Date | 2019-03-27 |
| Last Update Date | 2025-07-18 |