| NPI | 1598776106 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-09133) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2006-08-10 |
| Last Update Date | 2019-08-05 |