| NPI | 1679102289 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061412) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA005190) |
| Enumeration Date | 2020-04-06 |
| Last Update Date | 2020-07-06 |