| NPI | 1336495431 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA003301) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 60425) |
| 363A00000X Physician Assistant (Licence: PA MA056900) | |
| Enumeration Date | 2012-07-26 |
| Last Update Date | 2023-01-09 |