| NPI | 1679880066 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: MD C0004283) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: PA MA056654) |
| Enumeration Date | 2010-09-07 |
| Last Update Date | 2020-12-19 |