| NPI | 1063797447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: SC 1922) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA055229) |
| Enumeration Date | 2011-10-17 |
| Last Update Date | 2022-11-30 |