| NPI | 1699195735 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 2143) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 006237) |
| Enumeration Date | 2014-04-16 |
| Last Update Date | 2021-06-07 |