| NPI | 1730050006 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA067023) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0012360) |
| Enumeration Date | 2025-09-17 |
| Last Update Date | 2025-10-13 |