| NPI | 1659677458 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA058101) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110005976) |
| Enumeration Date | 2011-01-27 |
| Last Update Date | 2025-02-05 |