| NPI | 1669797049 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 721) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC A721) |
| 363AM0700X Physician Assistant Medical (Licence: SC A721) | |
| Enumeration Date | 2010-03-29 |
| Last Update Date | 2020-11-27 |