| NPI | 1548615206 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: IA 082549) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 2989) |
| 363A00000X Physician Assistant (Licence: IA 82549) | |
| Enumeration Date | 2016-05-02 |
| Last Update Date | 2020-10-28 |