| NPI | 1578951869 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA066585) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: VA 0110004831) | |
| Enumeration Date | 2015-01-08 |
| Last Update Date | 2025-08-19 |