| NPI | 1003574906 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13431) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1193217) |
| Enumeration Date | 2021-12-08 |
| Last Update Date | 2024-04-02 |