| NPI | 1598479370 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: 1204584) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1598479370) |
| Enumeration Date | 2023-01-06 |
| Last Update Date | 2025-08-05 |