| NPI | 1871628081 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-03669) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 2519) |
| Enumeration Date | 2007-02-21 |
| Last Update Date | 2024-10-23 |