| NPI | 1588644926 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT 107907) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SD 0583) |
| Enumeration Date | 2006-01-20 |
| Last Update Date | 2022-03-09 |