| NPI | 1720417249 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MT MED-PAC-LIC-28735) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT 00) |
| Enumeration Date | 2013-11-05 |
| Last Update Date | 2022-02-24 |