| NPI | 1518360007 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 2219) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 8344) |
| 363A00000X Physician Assistant (Licence: GA 008344) | |
| Enumeration Date | 2014-09-29 |
| Last Update Date | 2021-08-19 |