| NPI | 1265490098 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA 004775) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 4755) |
| Enumeration Date | 2006-05-02 |
| Last Update Date | 2020-02-07 |