| NPI | 1568896470 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-05114) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 5492) |
| Enumeration Date | 2013-08-27 |
| Last Update Date | 2015-02-11 |