| NPI | 1164941977 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07556) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL 9114062) |
| Enumeration Date | 2017-09-12 |
| Last Update Date | 2024-02-22 |