| NPI | 1124490255 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11248) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 7783) |
| Enumeration Date | 2015-10-28 |
| Last Update Date | 2021-08-20 |