| NPI | 1013499599 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110007594) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 7121) |
| Enumeration Date | 2018-08-31 |
| Last Update Date | 2022-08-16 |