| NPI | 1982220760 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA061777) |
| Enumeration Date | 2020-06-17 |
| Last Update Date | 2022-02-15 |