| NPI | 1861961955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: 1156474) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: CA 56411) |
| Enumeration Date | 2018-11-19 |
| Last Update Date | 2023-08-15 |