| NPI | 1710028956 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110001771) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0002853) |
| Enumeration Date | 2007-02-09 |
| Last Update Date | 2021-06-02 |