| NPI | 1164915203 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110006469) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C06998) |
| Enumeration Date | 2018-06-13 |
| Last Update Date | 2021-09-14 |