| NPI | 1063895621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA 11004) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA057651) |
| 363A00000X Physician Assistant (Licence: GA 11004) | |
| Enumeration Date | 2015-07-01 |
| Last Update Date | 2022-06-30 |