| NPI | 1033712070 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA005499) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA061980) |
| Enumeration Date | 2020-11-20 |
| Last Update Date | 2021-08-17 |