| NPI | 1225500630 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA060502) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2018-12-23 |
| Last Update Date | 2023-10-02 |