| NPI | 1902325491 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110-005928) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-13398) |
| Enumeration Date | 2017-09-15 |
| Last Update Date | 2025-09-13 |