| NPI | 1710295209 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AK PADA1165) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110003403) |
| Enumeration Date | 2010-09-17 |
| Last Update Date | 2022-09-26 |