| NPI | 1679180095 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110-008192) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2020-09-29 |
| Last Update Date | 2022-01-14 |