| NPI | 1699170688 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1423) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CO 0004137) |
| Enumeration Date | 2014-11-03 |
| Last Update Date | 2021-06-09 |