| NPI | 1700419041 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13881) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MS 1170747) |
| Enumeration Date | 2020-02-14 |
| Last Update Date | 2024-08-21 |