| NPI | 1700512746 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA064832) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 13035250-8906) |
| Enumeration Date | 2022-07-30 |
| Last Update Date | 2024-01-18 |