| NPI | 1215423512 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 9085) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 4893-23) |
| Enumeration Date | 2018-07-10 |
| Last Update Date | 2022-12-15 |