| NPI | 1548745854 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA212783) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 4275) |
| 363AM0700X Physician Assistant, Medical (Licence: CT 4275) | |
| Enumeration Date | 2018-10-02 |
| Last Update Date | 2022-10-21 |