| NPI | 1720556616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: DC PA200001774) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 225200000X Physical Therapy Assistant | |
| Enumeration Date | 2018-11-08 |
| Last Update Date | 2024-09-27 |