| NPI | 1073710158 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA053060) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C03532) |
| 363AM0700X Physician Assistant, Medical (Licence: MD C03532) | |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA053060) | |
| 363AM0700X Physician Assistant, Medical (Licence: MD T0003532) | |
| Enumeration Date | 2007-07-02 |
| Last Update Date | 2021-05-11 |