| NPI | 1083192942 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA059972) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA004560) |
| Enumeration Date | 2018-08-02 |
| Last Update Date | 2022-02-18 |