| NPI | 1669464392 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT 0292) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: MT 0292) |
| 363AS0400X Physician Assistant Surgical (Licence: MT 0292) | |
| Enumeration Date | 2005-08-18 |
| Last Update Date | 2013-06-25 |