| NPI | 1205570819 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 2736) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 112973) |
| Enumeration Date | 2022-04-21 |
| Last Update Date | 2022-04-21 |