| NPI | 1497429567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA062721) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA 1169824) |
| Enumeration Date | 2021-08-03 |
| Last Update Date | 2024-05-08 |