| NPI | 1134541246 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA056441) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA003139) |
| Enumeration Date | 2014-01-08 |
| Last Update Date | 2020-10-12 |