| NPI | 1134404262 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA8263) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 3008) |
| 363A00000X Physician Assistant (Licence: WA PA60251113) | |
| Enumeration Date | 2011-10-20 |
| Last Update Date | 2021-10-12 |