| NPI | 1972052298 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA058588) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA003914) |
| Enumeration Date | 2016-09-27 |
| Last Update Date | 2020-02-03 |