| NPI | 1053645978 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: VA 0110003156) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110003156) |
| Enumeration Date | 2009-09-24 |
| Last Update Date | 2022-05-27 |