| NPI | 1790169993 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-08621) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 1112) |
| 363A00000X Physician Assistant (Licence: MA PA5426) | |
| Enumeration Date | 2015-07-17 |
| Last Update Date | 2025-10-20 |