| NPI | 1376114991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA065496) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 10486) |
| Enumeration Date | 2021-07-06 |
| Last Update Date | 2024-08-21 |