| NPI | 1710077946 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 2087) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 001279) |
| 363A00000X Physician Assistant (Licence: SC TL2087) | |
| Enumeration Date | 2006-10-16 |
| Last Update Date | 2020-12-22 |