| NPI | 1306263603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-09785) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C05352) |
| Enumeration Date | 2014-03-25 |
| Last Update Date | 2021-07-07 |