| NPI | 1235438581 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AK 103960) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA054734) |
| Enumeration Date | 2011-03-24 |
| Last Update Date | 2021-04-07 |