| NPI | 1457451064 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 101035) |
| Additional Taxonomies | 208VP0000X Pain Medicine, Pain Medicine (Licence: NC 101035) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 101035) | |
| Enumeration Date | 2006-09-24 |
| Last Update Date | 2023-03-07 |