| NPI | 1154637932 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-08049) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 0868) |
| Enumeration Date | 2010-08-31 |
| Last Update Date | 2023-05-04 |