| NPI | 1831517333 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA 320838) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 2505) |
| Enumeration Date | 2014-04-01 |
| Last Update Date | 2021-06-10 |