| NPI | 1740565936 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AK 170547) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CA 21835) |
| Enumeration Date | 2011-10-19 |
| Last Update Date | 2023-11-29 |