| NPI | 1851611453 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110003303) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0012472) |
| Enumeration Date | 2010-06-04 |
| Last Update Date | 2026-08-04 |