| NPI | 1790145985 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 008307) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 6336) |
| Enumeration Date | 2016-03-01 |
| Last Update Date | 2018-12-20 |