| NPI | 1760067599 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061970) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2021-03-12 |
| Last Update Date | 2021-06-09 |