| NPI | 1932740602 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA063597) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: NC 0010-09618) | |
| Enumeration Date | 2019-10-03 |
| Last Update Date | 2022-07-19 |