| NPI | 1619593738 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12947) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0008074) |
| Enumeration Date | 2020-06-24 |
| Last Update Date | 2023-03-02 |