| NPI | 1255448361 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: LA A10512) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA PA.A10512.RX) |
| Enumeration Date | 2006-08-24 |
| Last Update Date | 2023-07-28 |