| NPI | 1902375744 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 7920) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-08571) |
| Enumeration Date | 2018-11-22 |
| Last Update Date | 2022-05-18 |