| NPI | 1275163529 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 12238) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA2228) |
| Enumeration Date | 2020-01-24 |
| Last Update Date | 2024-05-14 |