| NPI | 1982189122 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PA OT019168) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2018034280) |
| Enumeration Date | 2018-10-02 |
| Last Update Date | 2019-09-03 |