| NPI | 1336138866 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110005570) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1066163) |
| Enumeration Date | 2005-10-18 |
| Last Update Date | 2023-06-05 |