| NPI | 1740255231 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 3491) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WI 1378) |
| Enumeration Date | 2006-02-20 |
| Last Update Date | 2022-08-10 |