| NPI | 1730868019 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA006515) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA064608) |
| Enumeration Date | 2023-07-14 |
| Last Update Date | 2024-04-11 |