| NPI | 1083608913 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 2219) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT 99323) |
| Enumeration Date | 2005-09-07 |
| Last Update Date | 2021-09-17 |