| NPI | 1023099314 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2021038900) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110001116) |
| Enumeration Date | 2005-11-14 |
| Last Update Date | 2021-11-11 |