| NPI | 1639857147 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA066094) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MA066094) |
| Enumeration Date | 2023-07-06 |
| Last Update Date | 2024-11-11 |