| NPI | 1467478396 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA003194) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: AZ 7129) | |
| Enumeration Date | 2006-07-14 |
| Last Update Date | 2021-09-15 |