| NPI | 1609969674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-02065) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 9102838) |
| 363A00000X Physician Assistant (Licence: FL PA 9102838) | |
| 363AM0700X Physician Assistant, Medical (Licence: GA 005331) | |
| Enumeration Date | 2006-10-02 |
| Last Update Date | 2025-07-28 |