| NPI | 1730894858 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110010278) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0008783) |
| Enumeration Date | 2023-01-23 |
| Last Update Date | 2025-10-10 |