| NPI | 1740489111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 1613) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-06443) |
| Enumeration Date | 2007-07-16 |
| Last Update Date | 2025-02-26 |