| NPI | 1811979669 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: HI 344) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AM0700X Physician Assistant, Medical (Licence: VA 0110006213) | |
| Enumeration Date | 2005-11-17 |
| Last Update Date | 2022-12-22 |