| NPI | 1992351662 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12054) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0011442) |
| Enumeration Date | 2019-08-17 |
| Last Update Date | 2023-01-03 |