| NPI | 1912376104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 9515458-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 024950) |
| 363A00000X Physician Assistant (Licence: FL PA9113223) | |
| 363A00000X Physician Assistant (Licence: CT 4802) | |
| 363A00000X Physician Assistant (Licence: OH 50.006414RX) | |
| 363A00000X Physician Assistant (Licence: TN 4128) | |
| 363A00000X Physician Assistant (Licence: VA 0110-007165) | |
| 363A00000X Physician Assistant (Licence: MI 5601009907) | |
| 363A00000X Physician Assistant (Licence: SC 3545) | |
| 363A00000X Physician Assistant (Licence: WI 8511) | |
| Enumeration Date | 2015-09-18 |
| Last Update Date | 2025-09-10 |