| NPI | 1942802376 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 10297) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY 1179376) |
| Enumeration Date | 2020-11-10 |
| Last Update Date | 2021-03-05 |