| NPI | 1629969746 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA007297) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA066716) |
| Enumeration Date | 2025-07-15 |
| Last Update Date | 2025-07-15 |