| NPI | 1649261819 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: VA 0110002298) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical |
| Enumeration Date | 2005-11-04 |
| Last Update Date | 2025-07-01 |