| NPI | 1154672426 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MD C04849) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 9763) |
| Enumeration Date | 2012-09-27 |
| Last Update Date | 2020-06-26 |