| NPI | 1851938302 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-09767) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110010389) |
| Enumeration Date | 2019-12-03 |
| Last Update Date | 2024-12-04 |