| NPI | 1861044042 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 5784) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-09245) |
| Enumeration Date | 2019-07-09 |
| Last Update Date | 2025-04-02 |