| NPI | 1386661940 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA9361) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-05245) |
| 363A00000X Physician Assistant (Licence: PA MA063564) | |
| Enumeration Date | 2006-07-17 |
| Last Update Date | 2024-07-26 |