| NPI | 1902294572 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA PA09622) |
| Enumeration Date | 2015-01-05 |
| Last Update Date | 2022-08-01 |