| NPI | 1568461747 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: IA 002094) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: SD 0484) |
| Enumeration Date | 2005-07-19 |
| Last Update Date | 2023-03-07 |