| NPI | 1073716007 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-03056) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 005055) |
| Enumeration Date | 2007-06-07 |
| Last Update Date | 2023-01-17 |