| NPI | 1639682388 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061153) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA005047) |
| Enumeration Date | 2017-11-15 |
| Last Update Date | 2022-04-04 |