| NPI | 1851801823 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2020040966) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10002325A) |
| Enumeration Date | 2017-10-04 |
| Last Update Date | 2021-05-26 |