| NPI | 1720050453 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 2301) |
| Additional Taxonomies | 111N00000X Chiropractor (Licence: PA DC007082L) |
| 363AS0400X Physician Assistant Surgical (Licence: PA MA056731) | |
| Enumeration Date | 2006-02-06 |
| Last Update Date | 2024-11-03 |