| NPI | 1235520693 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MS PA00293) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA PA.200790) |
| Enumeration Date | 2015-02-06 |
| Last Update Date | 2019-11-14 |