| NPI | 1730609546 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 08393) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-09005) |
| Enumeration Date | 2017-06-22 |
| Last Update Date | 2025-07-11 |