| NPI | 1396304267 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 097575) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AM0700X Physician Assistant Medical (Licence: IA 097575) | |
| 363AS0400X Physician Assistant Surgical (Licence: IA 097575) | |
| Enumeration Date | 2019-06-13 |
| Last Update Date | 2021-09-16 |