| NPI | 1013494855 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DE C5-0011626) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA059924) |
| Enumeration Date | 2018-07-24 |
| Last Update Date | 2021-11-09 |