| NPI | 1962988410 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 3880) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TN 3664) |
| 363AS0400X Physician Assistant, Surgical (Licence: TN 3664) | |
| Enumeration Date | 2018-07-18 |
| Last Update Date | 2021-09-03 |