| NPI | 1619926045 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA052330) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0012218) |
| Enumeration Date | 2006-05-10 |
| Last Update Date | 2025-03-04 |