| NPI | 1902315625 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-10558) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MD C06610) |
| Enumeration Date | 2017-09-26 |
| Last Update Date | 2023-04-06 |