| NPI | 1336148675 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 602) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 102904) |
| 363AM0700X Physician Assistant, Medical (Licence: SC A602) | |
| Enumeration Date | 2005-07-19 |
| Last Update Date | 2022-11-04 |