| NPI | 1710403621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 096160) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TN 3399) |
| Enumeration Date | 2017-08-22 |
| Last Update Date | 2021-02-22 |