| NPI | 1184659385 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA 1163) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 001528) |
| Enumeration Date | 2006-07-12 |
| Last Update Date | 2020-08-26 |