| NPI | 1942865290 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA 11989) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA060652) |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA060652) | |
| Enumeration Date | 2019-05-02 |
| Last Update Date | 2023-12-07 |