| NPI | 1558372011 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 2821) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 3104) |
| 363A00000X Physician Assistant (Licence: NC 0010-04439) | |
| Enumeration Date | 2006-08-10 |
| Last Update Date | 2022-07-21 |