| NPI | 1851095905 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DC PA200001642) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2024017813) |
| Enumeration Date | 2023-03-30 |
| Last Update Date | 2024-08-20 |