| NPI | 1144995655 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11791) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2021-08-16 |
| Last Update Date | 2023-05-16 |