| NPI | 1073332631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-14703) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-14703) |
| Enumeration Date | 2024-10-09 |
| Last Update Date | 2024-12-09 |