| NPI | 1821336306 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110004140) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2013-01-18 |
| Last Update Date | 2020-02-13 |