| NPI | 1710372446 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 201812813) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA PA.200807) |
| Enumeration Date | 2015-03-31 |
| Last Update Date | 2023-02-28 |