| NPI | 1821707852 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110009097) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-12783) |
| Enumeration Date | 2022-11-17 |
| Last Update Date | 2023-09-27 |