| NPI | 1790010825 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 1468) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: SC TL1468) |
| Enumeration Date | 2009-10-07 |
| Last Update Date | 2024-11-03 |