| NPI | 1790884617 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-08955) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 003215) |
| Enumeration Date | 2006-09-21 |
| Last Update Date | 2019-05-20 |