| NPI | 1457781254 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA056320) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA61333527) |
| 363A00000X Physician Assistant (Licence: NY 019076) | |
| 363AM0700X Physician Assistant, Medical (Licence: CA 23140) | |
| Enumeration Date | 2013-11-15 |
| Last Update Date | 2024-07-11 |