| NPI | 1629726641 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-15910) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110009119) |
| Enumeration Date | 2022-03-17 |
| Last Update Date | 2026-01-09 |