| NPI | 1740902410 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PR 001312-P.A.) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 9834) |
| 363A00000X Physician Assistant (Licence: OH 50.009517RX) | |
| 363AM0700X Physician Assistant, Medical (Licence: FL TPPA389) | |
| Enumeration Date | 2022-09-19 |
| Last Update Date | 2025-12-06 |