| NPI | 1679569982 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0001647) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MD C0001647) |
| Enumeration Date | 2005-09-22 |
| Last Update Date | 2013-12-05 |