| NPI | 1083441455 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA065973) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA007015) |
| Enumeration Date | 2024-09-18 |
| Last Update Date | 2024-09-18 |