| NPI | 1154895829 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13196) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 305900) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 0010-13196) | |
| 363AS0400X Physician Assistant, Surgical (Licence: NY 023159) | |
| Enumeration Date | 2019-01-16 |
| Last Update Date | 2024-06-20 |