| NPI | 1881640449 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA000204L) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: PA MA000490L) |
| Enumeration Date | 2006-05-25 |
| Last Update Date | 2025-09-11 |