| NPI | 1578347589 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR 222888) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 9769) |
| Enumeration Date | 2023-08-21 |
| Last Update Date | 2025-01-23 |