| NPI | 1770056566 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NV PA2082) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 025290) |
| Enumeration Date | 2019-01-04 |
| Last Update Date | 2024-06-18 |