| NPI | 1679909873 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA PA200670) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: LA PA.200670) |
| Enumeration Date | 2013-09-19 |
| Last Update Date | 2023-12-11 |