| NPI | 1740363712 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MT MED-PAC-LIC-23) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT 23) |
| Enumeration Date | 2006-10-23 |
| Last Update Date | 2021-12-14 |