| NPI | 1780996892 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: FL 9105506) |
| Enumeration Date | 2010-07-06 |
| Last Update Date | 2017-08-01 |