| NPI | 1629723200 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110009709) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0009928) |
| Enumeration Date | 2022-02-13 |
| Last Update Date | 2025-07-21 |