NPI | 1518401272 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110005622) |
Additional Taxonomies | 363AS0400X Physician Assistant, Surgical |
363AM0700X Physician Assistant, Medical (Licence: VA 0110005622) | |
Enumeration Date | 2016-12-14 |
Last Update Date | 2025-09-11 |