| NPI | 1366908329 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA062850) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA004760) |
| Enumeration Date | 2019-02-14 |
| Last Update Date | 2023-03-23 |