| NPI | 1306850292 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA0586846) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA056846) |
| Enumeration Date | 2006-07-28 |
| Last Update Date | 2021-09-10 |