| NPI | 1902317571 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA060779) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2017-10-23 |
| Last Update Date | 2019-08-12 |