| NPI | 1376896811 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061531) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-04994) |
| 363AM0700X Physician Assistant, Medical (Licence: MD C04896) | |
| Enumeration Date | 2012-10-22 |
| Last Update Date | 2021-06-03 |