| NPI | 1447952965 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110009249) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 4762) |
| Enumeration Date | 2023-03-20 |
| Last Update Date | 2023-05-04 |