| NPI | 1689962581 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MD C004461) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9117365) |
| Enumeration Date | 2011-07-13 |
| Last Update Date | 2023-05-26 |