| NPI | 1043477672 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110003574) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 1081007) |
| Enumeration Date | 2008-05-21 |
| Last Update Date | 2020-05-18 |