| NPI | 1467638502 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C03707) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA OA003605) |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA057763) | |
| Enumeration Date | 2008-01-19 |
| Last Update Date | 2022-01-01 |