| NPI | 1881943363 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07207) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 2127) |
| Enumeration Date | 2012-08-30 |
| Last Update Date | 2022-04-26 |