| NPI | 1689127540 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110005230) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-06506) |
| Enumeration Date | 2016-07-27 |
| Last Update Date | 2026-02-25 |