| NPI | 1629012604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TN 5080) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 003567) |
| 363AM0700X Physician Assistant, Medical (Licence: GA 003567) | |
| Enumeration Date | 2006-06-16 |
| Last Update Date | 2026-03-03 |