| NPI | 1699497008 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12632) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-12632) | |
| Enumeration Date | 2022-09-13 |
| Last Update Date | 2026-01-09 |