| NPI | 1295142438 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: LA 335459) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0005571) |
| 363A00000X Physician Assistant (Licence: CA PA55577) | |
| 363AM0700X Physician Assistant, Medical (Licence: DC PA031051) | |
| Enumeration Date | 2014-07-21 |
| Last Update Date | 2024-04-12 |