| NPI | 1992177760 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 2460) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-08414) |
| Enumeration Date | 2015-10-20 |
| Last Update Date | 2026-01-14 |