| NPI | 1760206387 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MD C0009667) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA066674) |
| 363A00000X Physician Assistant (Licence: PA OA007286) | |
| Enumeration Date | 2024-11-11 |
| Last Update Date | 2025-09-09 |