| NPI | 1770090607 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AL PA-1317) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| 363AM0700X Physician Assistant, Medical (Licence: FL PA9112400) | |
| Enumeration Date | 2017-12-31 |
| Last Update Date | 2020-12-11 |