| NPI | 1174720866 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110007249) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 2160-023) |
| Enumeration Date | 2007-06-27 |
| Last Update Date | 2023-12-20 |