| NPI | 1568911832 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA058564) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA003917) |
| Enumeration Date | 2016-09-28 |
| Last Update Date | 2022-10-05 |