| NPI | 1376140855 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12146) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 5625) |
| Enumeration Date | 2020-10-07 |
| Last Update Date | 2024-09-30 |