| NPI | 1780103325 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA059327) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2017-09-14 |
| Last Update Date | 2019-04-02 |