| NPI | 1295832301 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-01943) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA PA.200066) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2022-02-01 |