| NPI | 1992566137 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA102470) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0010017) |
| Enumeration Date | 2024-01-16 |
| Last Update Date | 2026-02-17 |