| NPI | 1588175996 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 6936) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA101012) |
| Enumeration Date | 2017-10-12 |
| Last Update Date | 2024-09-23 |