| NPI | 1639170723 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AL PA225) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9108726) |
| 363A00000X Physician Assistant (Licence: AL PA.255) | |
| 207P00000X Emergency Medicine (Licence: AL PA.255) | |
| 363AS0400X Physician Assistant, Surgical (Licence: AL PA225) | |
| Enumeration Date | 2005-08-10 |
| Last Update Date | 2021-02-04 |