| NPI | 1366960650 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 8011) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: WI 4195) |
| Enumeration Date | 2017-09-06 |
| Last Update Date | 2021-02-16 |