| NPI | 1972395507 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA007295) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA066701) |
| Enumeration Date | 2025-05-20 |
| Last Update Date | 2025-07-17 |