| NPI | 1154511707 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 4203) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: PA MA053049) |
| Enumeration Date | 2007-07-30 |
| Last Update Date | 2021-12-03 |