| NPI | 1578712592 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DE C5-0001005) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0005895) |
| 363A00000X Physician Assistant (Licence: AZ 5751) | |
| Enumeration Date | 2008-09-15 |
| Last Update Date | 2018-04-05 |