| NPI | 1104822592 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-05316) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: GA 003590) |
| Enumeration Date | 2005-06-22 |
| Last Update Date | 2023-12-15 |