NPI | 1669581500 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110002100) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-08694) |
Enumeration Date | 2006-08-30 |
Last Update Date | 2023-03-14 |