| NPI | 1114454659 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA PA321486) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2017-05-15 |
| Last Update Date | 2021-12-01 |