| NPI | 1205809852 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0202X Radiology, Diagnostic Radiology (Licence: ID PA-1042) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110002940) |
| 363A00000X Physician Assistant (Licence: WA PA10004399) | |
| 363A00000X Physician Assistant (Licence: OR PA 00846) | |
| 363AS0400X Physician Assistant, Surgical (Licence: MD C04233) | |
| Enumeration Date | 2006-02-13 |
| Last Update Date | 2022-01-31 |