| NPI | 1215642780 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2023001096) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 13174946-1206) |
| Enumeration Date | 2023-01-19 |
| Last Update Date | 2023-01-19 |