| NPI | 1679564926 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110003207) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DC PA119) |
| 363AM0700X Physician Assistant, Medical (Licence: SC PA 1211) | |
| Enumeration Date | 2005-11-03 |
| Last Update Date | 2016-07-15 |