| NPI | 1083970040 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NE 1628) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NE 1628) |
| Enumeration Date | 2012-04-04 |
| Last Update Date | 2020-09-22 |