| NPI | 1952882649 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AS0400X Physician Assistant Surgical | |
| Enumeration Date | 2018-08-22 |
| Last Update Date | 2020-03-26 |