| NPI | 1073851770 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06077) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 2453) |
| Enumeration Date | 2013-01-30 |
| Last Update Date | 2024-05-15 |