| NPI | 1689223604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 11008) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-09457) |
| 363AM0700X Physician Assistant Medical (Licence: NC 0010-09457) | |
| Enumeration Date | 2019-09-11 |
| Last Update Date | 2022-08-19 |