| NPI | 1528106895 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SD 0679) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 1290) |
| Enumeration Date | 2007-02-01 |
| Last Update Date | 2019-11-25 |