| NPI | 1851464200 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 2261) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA ma051041) |
| Enumeration Date | 2006-11-15 |
| Last Update Date | 2021-06-01 |