| NPI | 1679586804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA002109L) |
| Additional Taxonomies | 207P00000X Emergency Medicine (Licence: PA MA002109L) |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA002109L) | |
| 363AS0400X Physician Assistant, Surgical (Licence: PA MA002109L) | |
| Enumeration Date | 2006-08-15 |
| Last Update Date | 2020-12-30 |