| NPI | 1801807334 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 5034) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA000767L) |
| Enumeration Date | 2006-08-10 |
| Last Update Date | 2013-08-20 |