| NPI | 1649454281 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: IA 076828) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: CO 2461) |
| 363AM0700X Physician Assistant Medical (Licence: NE 1679) | |
| Enumeration Date | 2007-12-18 |
| Last Update Date | 2018-10-15 |