| NPI | 1790094449 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-03710) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA054601) |
| Enumeration Date | 2010-09-29 |
| Last Update Date | 2016-03-22 |