| NPI | 1205390242 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11957) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 5531) |
| Enumeration Date | 2019-01-23 |
| Last Update Date | 2024-10-21 |