| NPI | 1821658675 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA PA61266752) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: DE C5-0001315) |
| Enumeration Date | 2019-06-14 |
| Last Update Date | 2023-02-15 |