| NPI | 1306831383 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: SC 4073) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 101514) |
| Enumeration Date | 2005-09-15 |
| Last Update Date | 2022-07-27 |