| NPI | 1659072569 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0009861) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110010190) |
| Enumeration Date | 2023-03-16 |
| Last Update Date | 2025-03-13 |