| NPI | 1689220782 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA060743) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA004890) |
| Enumeration Date | 2019-08-14 |
| Last Update Date | 2025-06-22 |