| NPI | 1790220341 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110005643) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VA 0110005643) |
| Enumeration Date | 2017-01-05 |
| Last Update Date | 2026-06-15 |