| NPI | 1326582552 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA6007) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical |
| Enumeration Date | 2016-12-07 |
| Last Update Date | 2022-09-29 |