| NPI | 1245667518 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-09786) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA056449) |
| Enumeration Date | 2013-10-02 |
| Last Update Date | 2020-04-20 |