| NPI | 1265050744 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061651) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA005283) |
| Enumeration Date | 2020-07-10 |
| Last Update Date | 2020-11-13 |