| NPI | 1831612191 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VA 0110-005856) |
| Enumeration Date | 2017-07-19 |
| Last Update Date | 2023-06-05 |