| NPI | 1639162092 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL 9100972) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 001000163) |
| Enumeration Date | 2005-08-31 |
| Last Update Date | 2019-05-01 |