| NPI | 1316124084 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA 004010) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-00434) |
| Enumeration Date | 2008-01-24 |
| Last Update Date | 2019-03-21 |