| NPI | 1215906391 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-00338) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-0038) |
| Enumeration Date | 2006-03-14 |
| Last Update Date | 2020-03-17 |