| NPI | 1174557359 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 9219) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1071719) |
| Enumeration Date | 2006-07-11 |
| Last Update Date | 2021-12-23 |