| NPI | 1376135723 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 2567) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 129084) |
| Enumeration Date | 2021-02-08 |
| Last Update Date | 2024-12-31 |