| NPI | 1902481641 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA005637) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA061776) |
| Enumeration Date | 2021-03-15 |
| Last Update Date | 2021-05-25 |