| NPI | 1003055815 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT 79185) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 5084) |
| 363AM0700X Physician Assistant, Medical (Licence: MD c0003928) | |
| Enumeration Date | 2009-02-18 |
| Last Update Date | 2025-04-22 |