| NPI | 1639786320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110007541) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2020-09-26 |
| Last Update Date | 2021-01-05 |