| NPI | 1851799878 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 9346) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-05351) |
| Enumeration Date | 2014-12-08 |
| Last Update Date | 2019-11-18 |