| NPI | 1689234700 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA065790) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA005984) |
| Enumeration Date | 2019-06-20 |
| Last Update Date | 2025-09-15 |