| NPI | 1295102739 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110006685) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MP 091) |
| Enumeration Date | 2015-09-01 |
| Last Update Date | 2019-08-26 |