| NPI | 1881752780 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 5916) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-13979) |
| Enumeration Date | 2006-12-04 |
| Last Update Date | 2025-10-15 |