| NPI | 1720563794 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-14586) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA060367) |
| Enumeration Date | 2018-09-26 |
| Last Update Date | 2024-10-31 |