| NPI | 1194473074 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA 10938) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 10938) |
| Enumeration Date | 2022-03-10 |
| Last Update Date | 2022-04-14 |