| NPI | 1962998856 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID 7871978) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-100093) |
| Enumeration Date | 2018-07-03 |
| Last Update Date | 2026-04-06 |