| NPI | 1023402104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 2300) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC MPA.2300 PA) |
| Enumeration Date | 2015-03-26 |
| Last Update Date | 2017-05-11 |