| NPI | 1740356526 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA 333716) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110004808) |
| 363A00000X Physician Assistant (Licence: 1097209) | |
| Enumeration Date | 2006-11-25 |
| Last Update Date | 2025-07-14 |