| NPI | 1760853220 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 6279) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ CNA25597) |
| Enumeration Date | 2015-10-09 |
| Last Update Date | 2017-10-20 |