| NPI | 1356337042 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 001097) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: IA 001097) |
| Enumeration Date | 2005-09-27 |
| Last Update Date | 2023-07-02 |