| NPI | 1265628432 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110002639) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0126000825) |
| Enumeration Date | 2007-09-20 |
| Last Update Date | 2022-03-14 |