| NPI | 1255397873 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 3789) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: AZ 3789) |
| Enumeration Date | 2006-04-22 |
| Last Update Date | 2023-07-28 |