| NPI | 1164825956 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-05300) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-05300) |
| Enumeration Date | 2014-10-07 |
| Last Update Date | 2021-05-10 |