| NPI | 1801532676 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110008838) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-13270) |
| Enumeration Date | 2022-05-05 |
| Last Update Date | 2025-02-28 |