| NPI | 1235121716 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA050911) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9101650) |
| Enumeration Date | 2005-08-19 |
| Last Update Date | 2022-08-26 |