| NPI | 1073539771 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MS PA00845) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL pa 9100880) |
| Enumeration Date | 2006-07-14 |
| Last Update Date | 2025-01-23 |