| NPI | 1629678925 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA062804) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0011611) |
| Enumeration Date | 2020-10-27 |
| Last Update Date | 2023-12-03 |