| NPI | 1720670870 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11099) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 9113991) |
| Enumeration Date | 2021-02-10 |
| Last Update Date | 2023-03-21 |