| NPI | 1972900157 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-05455) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-62848) |
| Enumeration Date | 2014-12-03 |
| Last Update Date | 2024-06-25 |