| NPI | 1124698329 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA062935) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: PA MA062935) |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA062935) | |
| Enumeration Date | 2021-06-29 |
| Last Update Date | 2021-11-24 |