| NPI | 1750743894 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: MA PA5640) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA5640) |
| Enumeration Date | 2016-03-28 |
| Last Update Date | 2020-11-20 |