| NPI | 1740659309 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 2696) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C05927) |
| Enumeration Date | 2015-09-24 |
| Last Update Date | 2026-02-18 |