| NPI | 1720369416 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 1844) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 002245) |
| Enumeration Date | 2011-09-08 |
| Last Update Date | 2020-12-31 |