| NPI | 1922584507 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 3974) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA059875) |
| Enumeration Date | 2018-07-17 |
| Last Update Date | 2023-05-01 |