| NPI | 1063993707 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA004574) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OA004574) |
| Enumeration Date | 2018-08-21 |
| Last Update Date | 2020-08-30 |