NPI | 1407854789 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9107839) |
Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WI 833) |
363AM0700X Physician Assistant, Medical (Licence: MN 8884) | |
Enumeration Date | 2005-07-12 |
Last Update Date | 2024-02-21 |