| NPI | 1477212579 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 10750) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TN 4803) |
| Enumeration Date | 2021-12-16 |
| Last Update Date | 2022-01-24 |