| NPI | 1770131708 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13019) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2019-09-03 |
| Last Update Date | 2024-02-12 |