| NPI | 1639205792 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: PA MA001818L) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA-000216L) |
| Enumeration Date | 2007-02-25 |
| Last Update Date | 2022-07-29 |