| NPI | 1295459618 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA C0009031) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MD C0009031) |
| Enumeration Date | 2022-09-29 |
| Last Update Date | 2024-08-13 |