| NPI | 1528267010 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-02302) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 9101384) |
| Enumeration Date | 2007-07-13 |
| Last Update Date | 2021-12-14 |