| NPI | 1376106005 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: FL 9114693) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL 9114693) |
| Enumeration Date | 2019-04-18 |
| Last Update Date | 2021-11-23 |