| NPI | 1245774397 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 6741) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 10126252-1206) |
| Enumeration Date | 2016-12-08 |
| Last Update Date | 2018-03-17 |