| NPI | 1417952862 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA83) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-83) |
| Enumeration Date | 2005-06-14 |
| Last Update Date | 2021-08-05 |