| NPI | 1619958220 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 7041) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 0741) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 103322) | |
| Enumeration Date | 2005-11-10 |
| Last Update Date | 2025-08-13 |