| NPI | 1114940087 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA PA.A10372) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA A30094) |
| Enumeration Date | 2006-07-25 |
| Last Update Date | 2020-07-15 |