| NPI | 1659895266 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2019037194) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-07313) |
| Enumeration Date | 2017-07-26 |
| Last Update Date | 2019-11-20 |