| NPI | 1366488017 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2024032326) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 004436) |
| 363A00000X Physician Assistant (Licence: GA 4436) | |
| Enumeration Date | 2006-06-21 |
| Last Update Date | 2024-10-25 |