| NPI | 1851063150 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA 344931) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110008942) |
| Enumeration Date | 2021-10-04 |
| Last Update Date | 2026-05-19 |