| NPI | 1730723743 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110009549) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110009549) |
| Enumeration Date | 2019-11-01 |
| Last Update Date | 2024-06-11 |