| NPI | 1760109953 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2022046205) |
| Enumeration Date | 2022-10-27 |
| Last Update Date | 2025-01-14 |