NPI | 1710647631 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA 10869) |
Additional Taxonomies | 363A00000X Physician Assistant |
363AM0700X Physician Assistant, Medical | |
Enumeration Date | 2021-12-20 |
Last Update Date | 2025-07-16 |