| NPI | 1821658022 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA PA7135) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2019-06-19 |
| Last Update Date | 2021-02-08 |