| NPI | 1770133654 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061022) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-13032) |
| Enumeration Date | 2019-09-12 |
| Last Update Date | 2026-03-18 |