| NPI | 1104129378 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061698) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110003454) |
| Enumeration Date | 2010-12-10 |
| Last Update Date | 2020-10-01 |