| NPI | 1326198698 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE nccpa# 1063283) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MT MED-PAC-LIC-70835) |
| Enumeration Date | 2007-01-11 |
| Last Update Date | 2021-10-19 |