| NPI | 1053894873 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 3349) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-08522) |
| Enumeration Date | 2018-09-07 |
| Last Update Date | 2020-01-22 |