| NPI | 1053748616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2018011301) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 007036) |
| Enumeration Date | 2013-09-27 |
| Last Update Date | 2018-07-17 |