| NPI | 1306380266 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 9109950) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO 0005936) |
| 363A00000X Physician Assistant (Licence: CA 54044) | |
| Enumeration Date | 2016-12-12 |
| Last Update Date | 2023-02-06 |