| NPI | 1770785503 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: SC 647PA) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: SC A647) |
| Enumeration Date | 2007-06-04 |
| Last Update Date | 2022-07-18 |