| NPI | 1740632009 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 11011) |
| 363A00000X Physician Assistant (Licence: OH 50.009385RX) | |
| 363A00000X Physician Assistant (Licence: DE C5-0012247) | |
| 363A00000X Physician Assistant (Licence: IA 131332) | |
| Enumeration Date | 2016-07-11 |
| Last Update Date | 2025-03-26 |