| NPI | 1083769111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA AP2303) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NH 0661) |
| Enumeration Date | 2007-01-25 |
| Last Update Date | 2022-11-14 |