| NPI | 1578087151 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-10419) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA059148) |
| 363A00000X Physician Assistant (Licence: NC 0010-10419) | |
| Enumeration Date | 2017-07-26 |
| Last Update Date | 2021-04-28 |