| NPI | 1265052658 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0007593) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110-007287) |
| Enumeration Date | 2020-04-26 |
| Last Update Date | 2020-07-20 |