| NPI | 1053320101 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 988) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 8844) |
| Enumeration Date | 2006-08-07 |
| Last Update Date | 2024-02-05 |