| NPI | 1316526403 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11194) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 300999) |
| Enumeration Date | 2021-04-06 |
| Last Update Date | 2024-08-29 |