| NPI | 1093906042 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110009385) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 1856) |
| 363AM0700X Physician Assistant, Medical (Licence: VA 0110002576) | |
| Enumeration Date | 2007-08-06 |
| Last Update Date | 2024-07-25 |