| NPI | 1841739141 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110007161) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-07079) |
| Enumeration Date | 2017-02-20 |
| Last Update Date | 2022-01-20 |