| NPI | 1639542673 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA057846) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9110206) |
| Enumeration Date | 2015-11-12 |
| Last Update Date | 2026-05-30 |