| NPI | 1770093619 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2323) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 14343) |
| 363A00000X Physician Assistant (Licence: FL TPPA1292) | |
| 363A00000X Physician Assistant (Licence: UT 14244832-1206) | |
| 363A00000X Physician Assistant (Licence: AZ 6882) | |
| 363A00000X Physician Assistant (Licence: CA 66944) | |
| 363A00000X Physician Assistant (Licence: WA PAPA70046050) | |
| Enumeration Date | 2017-10-05 |
| Last Update Date | 2026-09-16 |