| NPI | 1336788090 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2019046725) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2019-12-29 |
| Last Update Date | 2020-10-27 |