| NPI | 1285048371 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA 8737) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VA 0110-004606) |
| Enumeration Date | 2014-06-17 |
| Last Update Date | 2019-11-05 |