| NPI | 1215538913 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061707) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA005306) |
| Enumeration Date | 2020-11-08 |
| Last Update Date | 2023-03-21 |