| NPI | 1992275614 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11452) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: PA MA060315) |
| 363AM0700X Physician Assistant Medical (Licence: NC 305855) | |
| Enumeration Date | 2018-11-26 |
| Last Update Date | 2023-05-03 |