| NPI | 1871669796 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0002049) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0000684) |
| Enumeration Date | 2006-11-24 |
| Last Update Date | 2021-09-13 |