| NPI | 1114779139 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110010013) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2024-04-03 |
| Last Update Date | 2024-06-25 |