| NPI | 1760991004 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DC PA031391) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C06616) |
| Enumeration Date | 2017-09-28 |
| Last Update Date | 2022-12-15 |