| NPI | 1487906277 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA 200591) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA PA.#792.EXAM) |
| Enumeration Date | 2012-10-04 |
| Last Update Date | 2020-07-31 |