| NPI | 1942766969 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061061) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2019-02-14 |
| Last Update Date | 2020-10-02 |