| NPI | 1104086222 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA2548) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA 2548) |
| Enumeration Date | 2008-06-12 |
| Last Update Date | 2021-03-29 |