| NPI | 1780397018 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 2867) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NE 1204103) |
| 363A00000X Physician Assistant (Licence: IA 118173) | |
| Enumeration Date | 2023-01-02 |
| Last Update Date | 2023-12-15 |