| NPI | 1861680704 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2020019036) |
| Enumeration Date | 2007-10-04 |
| Last Update Date | 2025-05-29 |