| NPI | 1699907758 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MD C04156) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110004660) |
| 363AM0700X Physician Assistant, Medical (Licence: DC PA030607) | |
| 363AM0700X Physician Assistant, Medical (Licence: MD C0004156) | |
| Enumeration Date | 2009-08-21 |
| Last Update Date | 2020-12-14 |