| NPI | 1851948210 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 3357) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 13504) |
| Enumeration Date | 2019-08-21 |
| Last Update Date | 2025-12-07 |