| NPI | 1639774029 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-91352) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2020-12-02 |
| Last Update Date | 2025-04-03 |