| NPI | 1316923865 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA002495L) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: FL PA9101800) |
| Enumeration Date | 2005-12-16 |
| Last Update Date | 2020-07-17 |