| NPI | 1639477409 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12289) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 2313) |
| 363A00000X Physician Assistant (Licence: VA 0110003479) | |
| Enumeration Date | 2011-03-03 |
| Last Update Date | 2022-08-04 |