| NPI | 1265834378 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110009964) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NE 0010-08944) |
| Enumeration Date | 2014-09-19 |
| Last Update Date | 2024-08-01 |