| NPI | 1063595437 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06354) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1073875) |
| Enumeration Date | 2006-10-21 |
| Last Update Date | 2023-05-10 |