| NPI | 1174510879 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 001165) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: IA 001165) |
| 207Q00000X Family Medicine (Licence: IA 01165) | |
| Enumeration Date | 2005-09-29 |
| Last Update Date | 2022-05-24 |