| NPI | 1205371176 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA 8579) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 1138829) |
| 363A00000X Physician Assistant (Licence: GA 8579) | |
| Enumeration Date | 2016-12-30 |
| Last Update Date | 2025-02-10 |