| NPI | 1730637307 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA058390) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA003864) |
| Enumeration Date | 2016-09-13 |
| Last Update Date | 2020-09-01 |