| NPI | 1699430058 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA062744) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA OA005761) |
| Enumeration Date | 2021-11-01 |
| Last Update Date | 2023-02-23 |