| NPI | 1669719720 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA000305L) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA002307L) |
| Enumeration Date | 2013-01-09 |
| Last Update Date | 2017-01-18 |