| NPI | 1588095285 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110004415) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 7760-23) |
| Enumeration Date | 2013-12-05 |
| Last Update Date | 2025-05-05 |