| NPI | 1508816570 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA 004108) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 004108) |
| Enumeration Date | 2006-05-11 |
| Last Update Date | 2024-05-23 |