| NPI | 1659766541 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C05750) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-05662) |
| Enumeration Date | 2015-03-30 |
| Last Update Date | 2024-10-07 |