| NPI | 1558658062 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110006139) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA056798) |
| Enumeration Date | 2011-07-05 |
| Last Update Date | 2022-01-07 |