| NPI | 1376652412 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13738) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 1423) |
| 363AM0700X Physician Assistant, Medical (Licence: MO 2014011852) | |
| Enumeration Date | 2006-08-30 |
| Last Update Date | 2024-01-18 |