| NPI | 1982075073 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-08654) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MD C0005900) |
| Enumeration Date | 2015-10-14 |
| Last Update Date | 2021-12-23 |