| NPI | 1376150185 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061844) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1161207) |
| Enumeration Date | 2020-09-25 |
| Last Update Date | 2021-02-05 |