| NPI | 1124646518 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 8160) |
| Additional Taxonomies | 207P00000X Emergency Medicine (Licence: AZ 8160) |
| 363AM0700X Physician Assistant Medical (Licence: AZ 8160) | |
| Enumeration Date | 2020-07-11 |
| Last Update Date | 2021-06-15 |