| NPI | 1154805729 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: ID PA-1641) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OR PA190592) |
| Enumeration Date | 2018-09-19 |
| Last Update Date | 2022-07-18 |