| NPI | 1447620695 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA057862) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: PA MA057862) |
| Enumeration Date | 2015-09-30 |
| Last Update Date | 2021-01-15 |