| NPI | 1760872808 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110005603) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-05417) |
| 363A00000X Physician Assistant (Licence: MT 41019) | |
| Enumeration Date | 2015-01-28 |
| Last Update Date | 2024-04-03 |