| NPI | 1629151501 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA000855L) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: PA MA000855L) |
| Enumeration Date | 2006-10-23 |
| Last Update Date | 2021-01-07 |