| NPI | 1588491518 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110010608) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2024-09-14 |
| Last Update Date | 2025-02-10 |