| NPI | 1710647631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA 10869) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2021-12-20 |
| Last Update Date | 2025-07-16 |