| NPI | 1730591595 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110-005562) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD 1127030) |
| Enumeration Date | 2014-05-28 |
| Last Update Date | 2022-06-01 |