| NPI | 1093753311 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-08886) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 2132) |
| Enumeration Date | 2006-06-02 |
| Last Update Date | 2019-02-20 |