| NPI | 1700067378 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT 56256) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CA 56256) |
| Enumeration Date | 2007-11-23 |
| Last Update Date | 2024-08-15 |