| NPI | 1649296096 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 1543) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 004438) |
| Enumeration Date | 2006-07-15 |
| Last Update Date | 2020-10-22 |