| NPI | 1215921705 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA000930l) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA OA000122l) |
| Enumeration Date | 2005-09-10 |
| Last Update Date | 2024-03-29 |