| NPI | 1851800627 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: PA OA004264) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: PA MA059313) |
| Enumeration Date | 2017-09-25 |
| Last Update Date | 2017-11-06 |