| NPI | 1568100030 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11008) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NC 0010-11008) |
| Enumeration Date | 2022-05-24 |
| Last Update Date | 2022-07-28 |