| NPI | 1487120606 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 3167) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-08545) |
| Enumeration Date | 2018-10-15 |
| Last Update Date | 2021-06-30 |