| NPI | 1750033163 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA063200) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA006036) |
| Enumeration Date | 2022-01-26 |
| Last Update Date | 2022-06-18 |