| NPI | 1104899012 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MD 0003438) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MD c0003438) |
| 363A00000X Physician Assistant (Licence: TN 3750) | |
| Enumeration Date | 2006-02-10 |
| Last Update Date | 2021-09-29 |