| NPI | 1255981841 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061076) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0001366) |
| Enumeration Date | 2019-09-16 |
| Last Update Date | 2022-02-01 |