| NPI | 1538883855 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA063867) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0011801) |
| 363A00000X Physician Assistant (Licence: PA OA006212) | |
| Enumeration Date | 2022-09-29 |
| Last Update Date | 2022-11-01 |