| NPI | 1770157117 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: 1194739) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: UT 14188622) | |
| Enumeration Date | 2021-05-19 |
| Last Update Date | 2025-04-07 |