| NPI | 1215214085 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA056084) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA002780) |
| 363AM0700X Physician Assistant, Medical (Licence: PA OA002780) | |
| Enumeration Date | 2011-11-08 |
| Last Update Date | 2021-01-09 |