| NPI | 1124530845 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110010529) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2017-11-03 |
| Last Update Date | 2024-11-26 |