| NPI | 1003171851 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 54486) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 1301) |
| 363A00000X Physician Assistant (Licence: FL 9108537) | |
| 363A00000X Physician Assistant (Licence: IA 002305) | |
| 363A00000X Physician Assistant (Licence: CO 0004506) | |
| Enumeration Date | 2012-07-09 |
| Last Update Date | 2021-03-31 |