| NPI | 1710920855 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 9819) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NE 1274) |
| 363AM0700X Physician Assistant Medical (Licence: NE 1274) | |
| Enumeration Date | 2006-06-14 |
| Last Update Date | 2024-09-09 |