| NPI | 1720060122 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 367H00000X Anesthesiologist Assistant (Licence: GA 2844) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 002844) |
| Enumeration Date | 2005-11-19 |
| Last Update Date | 2020-06-17 |