| NPI | 1811923337 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA 321865) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9102153) |
| Enumeration Date | 2006-06-25 |
| Last Update Date | 2023-01-31 |