| NPI | 1790107506 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-04733) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 3513) |
| Enumeration Date | 2014-01-14 |
| Last Update Date | 2022-04-14 |