| NPI | 1831136035 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 275) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110007797) |
| Enumeration Date | 2006-05-31 |
| Last Update Date | 2022-01-18 |