| NPI | 1043952062 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 4848) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110008823) |
| Enumeration Date | 2022-04-11 |
| Last Update Date | 2023-08-24 |