| NPI | 1265478648 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA055359) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 7606) |
| 363A00000X Physician Assistant (Licence: CA 58320) | |
| 363AM0700X Physician Assistant, Medical (Licence: ID PA-597) | |
| Enumeration Date | 2006-06-22 |
| Last Update Date | 2025-01-10 |