| NPI | 1104035948 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0006192) |
| Additional Taxonomies | 133V00000X Dietitian, Registered (Licence: DC DI100000841) |
| 133V00000X Dietitian, Registered (Licence: MD DX2623) | |
| 363A00000X Physician Assistant (Licence: DC PA031262) | |
| 363AM0700X Physician Assistant, Medical (Licence: MD C0006192) | |
| 363AM0700X Physician Assistant, Medical (Licence: DC PA031262) | |
| Enumeration Date | 2007-05-21 |
| Last Update Date | 2024-04-10 |