| NPI | 1699008169 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-02014) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 3712) |
| Enumeration Date | 2009-09-15 |
| Last Update Date | 2025-10-21 |