| NPI | 1649993528 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110009649) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0110009649) |
| Enumeration Date | 2022-09-26 |
| Last Update Date | 2024-04-08 |