| NPI | 1710500558 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-11303) |
| Enumeration Date | 2020-05-27 |
| Last Update Date | 2021-09-29 |