| NPI | 1801278064 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA PA.200829) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: LA PA.200829) |
| 363AS0400X Physician Assistant, Surgical (Licence: LA PA.200829) | |
| Enumeration Date | 2015-06-24 |
| Last Update Date | 2019-02-18 |