| NPI | 1376919456 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MD C0006528) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VA 0110005753) |
| 363AM0700X Physician Assistant, Medical (Licence: CA 52689) | |
| Enumeration Date | 2015-08-12 |
| Last Update Date | 2022-07-21 |