| NPI | 1033792742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110008883) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 3994) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2021-04-30 |
| Last Update Date | 2023-08-11 |