| NPI | 1093234213 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13507) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 4594) |
| Enumeration Date | 2017-09-19 |
| Last Update Date | 2023-10-16 |