| NPI | 1689299737 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11637) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA2420) |
| Enumeration Date | 2020-06-15 |
| Last Update Date | 2024-07-19 |