| NPI | 1720430887 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA060618) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-06591) |
| Enumeration Date | 2016-07-12 |
| Last Update Date | 2024-03-04 |