| NPI | 1669734455 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA060552) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 5149) |
| Enumeration Date | 2012-06-08 |
| Last Update Date | 2020-08-28 |