| NPI | 1558381129 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 5615) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 7760) |
| Enumeration Date | 2006-07-19 |
| Last Update Date | 2023-08-16 |