| NPI | 1720551260 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-11226) |
| Enumeration Date | 2019-01-08 |
| Last Update Date | 2024-02-19 |