| NPI | 1538678875 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 9445) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO 1146308) |
| Enumeration Date | 2017-09-28 |
| Last Update Date | 2020-02-04 |