| NPI | 1508377250 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA059486) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA OA004323) |
| Enumeration Date | 2017-10-21 |
| Last Update Date | 2017-10-21 |