| NPI | 1679460349 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 6629) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 13306) |
| Enumeration Date | 2025-06-23 |
| Last Update Date | 2025-10-22 |