| NPI | 1578038337 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 9011) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: SC 3107) |
| Enumeration Date | 2018-10-09 |
| Last Update Date | 2025-02-07 |