| NPI | 1881990380 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 1565) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 091718) |
| Enumeration Date | 2011-01-31 |
| Last Update Date | 2025-06-06 |