| NPI | 1780398180 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13241) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2023-01-10 |
| Last Update Date | 2026-04-24 |