| NPI | 1598828923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 009532) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 1114) |
| 363AM0700X Physician Assistant, Medical (Licence: TN 1114) | |
| Enumeration Date | 2006-12-18 |
| Last Update Date | 2019-11-18 |