| NPI | 1083951420 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA058440) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2012036276) |
| Enumeration Date | 2013-01-04 |
| Last Update Date | 2021-07-01 |