| NPI | 1922615814 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110007892) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 62659) |
| Enumeration Date | 2020-09-25 |
| Last Update Date | 2025-11-10 |