| NPI | 1740232966 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-00323) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 1000323) |
| Enumeration Date | 2006-05-16 |
| Last Update Date | 2022-02-01 |