| NPI | 1518952506 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA004633) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA-002777-L) |
| Enumeration Date | 2005-09-15 |
| Last Update Date | 2022-08-08 |