| NPI | 1457447013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 756) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 107710) |
| Enumeration Date | 2006-10-04 |
| Last Update Date | 2024-11-21 |