| NPI | 1568560761 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: MD C0007193) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: PA MA057338) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2019-07-31 |