| NPI | 1851788590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 6398) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 55006641206) |
| Enumeration Date | 2015-04-21 |
| Last Update Date | 2021-01-28 |