| NPI | 1588346308 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID 7871273) |
| Additional Taxonomies | 2085N0904X (Licence: OR 918273) |
| Enumeration Date | 2023-08-01 |
| Last Update Date | 2025-09-23 |