| NPI | 1225767668 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA063589) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MF7282685) |
| 363AM0700X Physician Assistant, Medical (Licence: PA OA006103) | |
| Enumeration Date | 2022-06-09 |
| Last Update Date | 2022-08-18 |