| NPI | 1053830760 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110008494) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2017-09-13 |
| Last Update Date | 2024-05-14 |