| NPI | 1720552771 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110011724) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA060597) |
| Enumeration Date | 2019-01-13 |
| Last Update Date | 2026-03-18 |