| NPI | 1760636591 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA053029) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0008944) |
| Enumeration Date | 2008-11-06 |
| Last Update Date | 2023-08-15 |