| NPI | 1790950269 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 008847) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL pa9104370) |
| Enumeration Date | 2008-04-25 |
| Last Update Date | 2018-07-18 |