| NPI | 1811664584 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13853) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 11439) |
| Enumeration Date | 2021-08-30 |
| Last Update Date | 2024-03-22 |