| NPI | 1316411796 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-08861) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2019-01-18 |
| Last Update Date | 2019-03-14 |