| NPI | 1629156880 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA052044) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0000480) |
| Enumeration Date | 2006-11-02 |
| Last Update Date | 2025-09-05 |