| NPI | 1285019216 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110005700) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MA PA5452) |
| Enumeration Date | 2015-07-20 |
| Last Update Date | 2021-09-07 |