| NPI | 1821383332 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110004512) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA054895) |
| Enumeration Date | 2011-06-13 |
| Last Update Date | 2024-03-28 |