| NPI | 1154795227 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-08659) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 3643-23) |
| Enumeration Date | 2015-11-30 |
| Last Update Date | 2023-03-07 |