| NPI | 1487009759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06234) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: SC 2522) |
| Enumeration Date | 2016-04-25 |
| Last Update Date | 2023-07-21 |