| NPI | 1902629835 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AK 234425) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-14835) |
| Enumeration Date | 2024-11-07 |
| Last Update Date | 2025-07-25 |