| NPI | 1588107940 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA003933) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA058610) |
| Enumeration Date | 2016-12-02 |
| Last Update Date | 2020-02-15 |