| NPI | 1356839500 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA059758) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2018-04-24 |
| Last Update Date | 2023-11-07 |