| NPI | 1801572763 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-15272) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110009741) |
| Enumeration Date | 2023-06-26 |
| Last Update Date | 2025-08-18 |