| NPI | 1821634585 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA063965) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: PA PT027578) |
| Enumeration Date | 2019-11-18 |
| Last Update Date | 2022-12-30 |