| NPI | 1982623625 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110002037) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-00505) |
| Enumeration Date | 2006-07-19 |
| Last Update Date | 2025-03-31 |