| NPI | 1700618162 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AL 2467) |
| Enumeration Date | 2024-08-15 |
| Last Update Date | 2024-11-14 |