| NPI | 1912478140 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 001009372) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110006660) |
| Enumeration Date | 2018-12-16 |
| Last Update Date | 2021-07-15 |