| NPI | 1124307665 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-915) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA915) |
| Enumeration Date | 2011-08-16 |
| Last Update Date | 2024-03-11 |