| NPI | 1790082790 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2018029736) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA P.A.200418) |
| Enumeration Date | 2011-02-28 |
| Last Update Date | 2018-09-04 |