| NPI | 1588974265 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA057541) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0004364) |
| Enumeration Date | 2010-10-15 |
| Last Update Date | 2025-10-13 |