| NPI | 1245902949 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA062847) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA005804) |
| Enumeration Date | 2021-09-30 |
| Last Update Date | 2021-10-14 |