| NPI | 1316258262 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110003328) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA PA.200780) |
| Enumeration Date | 2010-06-25 |
| Last Update Date | 2020-04-02 |