| NPI | 1245378462 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA955) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: MA 955) |
| Enumeration Date | 2007-02-01 |
| Last Update Date | 2022-04-20 |