| NPI | 1225460298 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT 66952) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: PA MA056269) |
| Enumeration Date | 2013-08-01 |
| Last Update Date | 2021-05-18 |