| NPI | 1497181879 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MS PA00346) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA056386) |
| 363A00000X Physician Assistant (Licence: VA 0110006544) | |
| Enumeration Date | 2013-09-18 |
| Last Update Date | 2025-02-18 |