| NPI | 1477517217 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA PA243) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: AR PA243) |
| 363AS0400X Physician Assistant Surgical (Licence: AR PA243) | |
| Enumeration Date | 2006-04-17 |
| Last Update Date | 2025-04-01 |