| NPI | 1619218724 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110007090) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CO 0004117) |
| Enumeration Date | 2013-03-14 |
| Last Update Date | 2023-09-01 |