| NPI | 1588144604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110007438) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C07109) |
| 363AM0700X Physician Assistant Medical | |
| Enumeration Date | 2018-08-17 |
| Last Update Date | 2020-09-15 |