| NPI | 1205970365 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2018044339) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AR PA-263) |
| Enumeration Date | 2007-02-20 |
| Last Update Date | 2021-05-26 |