| NPI | 1417431792 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA060116) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA004613) |
| Enumeration Date | 2018-09-21 |
| Last Update Date | 2020-11-30 |