| NPI | 1255976395 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061243) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA005097) |
| Enumeration Date | 2019-11-13 |
| Last Update Date | 2025-02-06 |