NPI | 1609321868 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061364) |
Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MD C06203) |
Enumeration Date | 2016-08-17 |
Last Update Date | 2021-02-01 |