| NPI | 1003989799 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-00694) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 1262) |
| 363AM0700X Physician Assistant, Medical (Licence: SC 1262) | |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2006-11-17 |
| Last Update Date | 2021-04-27 |