| NPI | 1649514811 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA055901) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0000851) |
| Enumeration Date | 2012-11-12 |
| Last Update Date | 2019-12-09 |