| NPI | 1750861779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061665) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0001235) |
| Enumeration Date | 2018-08-20 |
| Last Update Date | 2024-06-13 |