| NPI | 1356636385 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA 006176) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-04889) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2011-06-17 |
| Last Update Date | 2021-02-24 |