| NPI | 1679467732 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PR 002557) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL TPPA977) |
| Enumeration Date | 2025-06-04 |
| Last Update Date | 2025-07-28 |