| NPI | 1881662542 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061339) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VA 0110002522) |
| Enumeration Date | 2006-03-09 |
| Last Update Date | 2020-08-24 |