| NPI | 1477598464 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: DC PA30142) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110001150) |
| Enumeration Date | 2006-06-17 |
| Last Update Date | 2020-11-02 |