| NPI | 1699705103 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: SC TL1317) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 102612) |
| Enumeration Date | 2006-07-03 |
| Last Update Date | 2023-03-07 |