| NPI | 1821516527 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: LA 306986) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: LA 306986) |
| Enumeration Date | 2017-09-01 |
| Last Update Date | 2020-03-03 |