| 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 |