| NPI | 1093184889 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06384) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC LL2413) |
| Enumeration Date | 2015-09-22 |
| Last Update Date | 2020-10-26 |