| NPI | 1679510747 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 367H00000X Anesthesiologist Assistant (Licence: GA 000989) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 000989) |
| Enumeration Date | 2006-05-31 |
| Last Update Date | 2020-04-20 |