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 | 2024-10-03 |