| NPI | 1245768068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 11246) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA059020) |
| Enumeration Date | 2017-05-24 |
| Last Update Date | 2023-07-12 |