NPI | 1902325491 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110-005928) |
Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-13398) |
Enumeration Date | 2017-09-15 |
Last Update Date | 2025-09-13 |