| NPI | 1497729180 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110004952) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA002319L) |
| Enumeration Date | 2006-02-17 |
| Last Update Date | 2020-03-03 |