| NPI | 1831510023 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA 200684) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MS PA00658) |
| Enumeration Date | 2013-12-15 |
| Last Update Date | 2023-01-04 |