| NPI | 1235567116 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11320) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9107582) |
| Enumeration Date | 2013-10-31 |
| Last Update Date | 2023-05-15 |