| NPI | 1356503973 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: SC 1608) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 1608) |
| 363A00000X Physician Assistant (Licence: SC 1608PM) | |
| 363AM0700X Physician Assistant Medical (Licence: NC 001001381) | |
| Enumeration Date | 2008-06-25 |
| Last Update Date | 2022-11-04 |