| NPI | 1255710885 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2023008003) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: AZ 8555) | |
| Enumeration Date | 2015-05-28 |
| Last Update Date | 2023-05-26 |