| NPI | 1699769794 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 1961) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 000861) |
| Enumeration Date | 2005-09-02 |
| Last Update Date | 2021-06-11 |