| NPI | 1700625092 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 6037) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110011457) |
| Enumeration Date | 2024-05-24 |
| Last Update Date | 2026-01-26 |