| NPI | 1184076036 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA059293) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA004257) |
| Enumeration Date | 2016-07-04 |
| Last Update Date | 2022-07-01 |