| NPI | 1164673950 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 001004572) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA ma053631) |
| Enumeration Date | 2008-10-10 |
| Last Update Date | 2019-05-31 |