| NPI | 1770263063 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DE C5-0012159) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0009658) |
| Enumeration Date | 2023-07-20 |
| Last Update Date | 2024-10-18 |