| NPI | 1114397742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: GA 8573) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0007177) |
| 363A00000X Physician Assistant (Licence: MN 12181) | |
| 363AS0400X Physician Assistant, Surgical (Licence: AZ 6155) | |
| Enumeration Date | 2015-09-24 |
| Last Update Date | 2024-01-31 |