| NPI | 1225097710 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 1190) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 001823) |
| Enumeration Date | 2006-03-22 |
| Last Update Date | 2020-12-30 |