| NPI | 1245579200 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2021024722) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA055982) |
| 363AM0700X Physician Assistant Medical (Licence: PA MA055982) | |
| 363AS0400X Physician Assistant Surgical (Licence: PA MA055982) | |
| Enumeration Date | 2013-02-11 |
| Last Update Date | 2021-08-18 |