| NPI | 1255754925 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 097917) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SD 0902) |
| Enumeration Date | 2014-01-30 |
| Last Update Date | 2021-10-28 |