| NPI | 1235862012 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL 9118992) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX 1198847) |
| Enumeration Date | 2022-07-07 |
| Last Update Date | 2024-10-04 |