| NPI | 1598009284 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA062720) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0001217) |
| Enumeration Date | 2012-11-19 |
| Last Update Date | 2022-04-15 |