| NPI | 1538624135 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 10786) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA6809) |
| Enumeration Date | 2019-02-07 |
| Last Update Date | 2022-04-18 |