| NPI | 1710333083 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-08541) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 1168) |
| Enumeration Date | 2016-05-05 |
| Last Update Date | 2019-01-04 |