| NPI | 1972863009 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA055575) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA002880) |
| Enumeration Date | 2012-05-23 |
| Last Update Date | 2021-01-21 |