| NPI | 1346661436 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 1782) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NE 1782) |
| 363AM0700X Physician Assistant, Medical (Licence: IA 002471) | |
| Enumeration Date | 2013-12-17 |
| Last Update Date | 2020-10-05 |