| NPI | 1134765324 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11254) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: PA MA061134) |
| Enumeration Date | 2019-11-22 |
| Last Update Date | 2021-06-14 |