| NPI | 1194261933 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110008080) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 3761) |
| 363L00000X Nurse Practitioner (Licence: MD C0007576) | |
| Enumeration Date | 2017-01-18 |
| Last Update Date | 2022-03-23 |