| NPI | 1083685192 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA058398) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: VA 2305006582) |
| Enumeration Date | 2006-01-27 |
| Last Update Date | 2021-11-29 |