| NPI | 1063077691 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA060877) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA004921) |
| Enumeration Date | 2019-05-09 |
| Last Update Date | 2023-05-25 |