NPI | 1376144105 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA062191) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA005462) |
363A00000X Physician Assistant (Licence: FL PA9113667) | |
363A00000X Physician Assistant | |
Enumeration Date | 2020-11-06 |
Last Update Date | 2022-01-04 |