| NPI | 1891450284 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C08309) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA063039) |
| Enumeration Date | 2021-11-01 |
| Last Update Date | 2022-06-03 |