| NPI | 1972228799 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA064172) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA006269) |
| Enumeration Date | 2022-10-04 |
| Last Update Date | 2025-07-21 |