| NPI | 1770972184 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 1501801) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ME PA2321) |
| 363A00000X Physician Assistant (Licence: VA 0110005063) | |
| 363A00000X Physician Assistant (Licence: NY 024081-01) | |
| Enumeration Date | 2015-01-22 |
| Last Update Date | 2025-10-21 |