| NPI | 1629361373 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 002196) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2011008552) |
| Enumeration Date | 2011-05-26 |
| Last Update Date | 2024-04-18 |