| NPI | 1457624819 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11242) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL PA813) |
| Enumeration Date | 2012-02-15 |
| Last Update Date | 2022-05-26 |