| NPI | 1306480462 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11125) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 9112757) |
| Enumeration Date | 2019-11-01 |
| Last Update Date | 2021-04-08 |