| NPI | 1588342893 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA064670) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA006536) |
| Enumeration Date | 2023-07-06 |
| Last Update Date | 2023-07-28 |