| NPI | 1255861712 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-09681) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2017-06-18 |
| Last Update Date | 2021-05-26 |