| NPI | 1871907105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 53342) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110004697) |
| 363A00000X Physician Assistant (Licence: DC PA031038) | |
| 363A00000X Physician Assistant (Licence: MD C0005385) | |
| 363AS0400X Physician Assistant, Surgical (Licence: MD C05385) | |
| Enumeration Date | 2014-06-14 |
| Last Update Date | 2020-02-17 |