NPI | 1760872808 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-05417) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT 41019) |
363A00000X Physician Assistant (Licence: VA 0110005603) | |
Enumeration Date | 2015-01-28 |
Last Update Date | 2024-09-10 |