| NPI | 1790767663 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 001297) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MT 246) |
| 363AM0700X Physician Assistant, Medical (Licence: AK 803) | |
| Enumeration Date | 2005-11-16 |
| Last Update Date | 2015-05-06 |