| NPI | 1811340565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: MT 142751) | |
| Enumeration Date | 2016-07-18 |
| Last Update Date | 2024-12-03 |