| NPI | 1114496585 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110006480) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0007052) |
| Enumeration Date | 2018-11-15 |
| Last Update Date | 2023-02-27 |