| NPI | 1265079503 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-09625) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 0010-09625) |
| Enumeration Date | 2019-12-05 |
| Last Update Date | 2021-03-24 |