| NPI | 1306559810 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 146L00000X Emergency Medical Technician, Paramedic |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2022-12-29 |
| Last Update Date | 2022-12-29 |