| NPI | 1629839113 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: HI A00910) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA100427) |
| 363AM0700X Physician Assistant, Medical (Licence: MA PA100427) | |
| Enumeration Date | 2024-01-22 |
| Last Update Date | 2025-10-17 |