| NPI | 1467479550 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MS PA00079) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9103513) |
| Enumeration Date | 2006-07-16 |
| Last Update Date | 2021-10-19 |