| NPI | 1528136868 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 469) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 469) |
| 363A00000X Physician Assistant (Licence: IA 109358) | |
| Enumeration Date | 2006-12-04 |
| Last Update Date | 2023-12-11 |