| NPI | 1063783074 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA057357) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9106297) |
| Enumeration Date | 2012-01-23 |
| Last Update Date | 2021-04-09 |