| NPI | 1154983757 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA060824) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2019-07-03 |
| Last Update Date | 2022-05-12 |