| NPI | 1902460603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 9803) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL 2426) |
| Enumeration Date | 2019-04-28 |
| Last Update Date | 2026-02-23 |