| NPI | 1558828632 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 110785) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NE 2407) |
| Enumeration Date | 2019-02-26 |
| Last Update Date | 2021-12-14 |