| NPI | 1063469864 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-01452) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA 1877) |
| Enumeration Date | 2006-05-27 |
| Last Update Date | 2020-09-10 |