| NPI | 1225672793 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA006404) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA061256) |
| Enumeration Date | 2019-10-29 |
| Last Update Date | 2024-06-13 |