| NPI | 1649986365 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DE C5-0011939) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C08756) |
| Enumeration Date | 2023-01-26 |
| Last Update Date | 2023-08-08 |