| NPI | 1720186109 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 2071) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 001018) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2019-07-31 |