| NPI | 1407280159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12002) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 5482) |
| Enumeration Date | 2013-08-29 |
| Last Update Date | 2022-09-23 |