| NPI | 1043856859 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061242) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA005076) |
| Enumeration Date | 2019-11-27 |
| Last Update Date | 2024-04-05 |