| NPI | 1174543532 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0002608) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA003097) |
| 363AM0700X Physician Assistant Medical (Licence: PA MA051226) | |
| Enumeration Date | 2006-07-20 |
| Last Update Date | 2022-04-07 |