| NPI | 1053764993 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA5829) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical |
| Enumeration Date | 2016-07-15 |
| Last Update Date | 2020-11-14 |