| NPI | 1669095733 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11306) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2020-05-25 |
| Last Update Date | 2023-01-10 |