| NPI | 1487042461 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: PA OA003465) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: PA MA057399) |
| Enumeration Date | 2014-12-29 |
| Last Update Date | 2022-03-03 |