| NPI | 1881945467 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: LA 329650) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical |
| Enumeration Date | 2012-09-24 |
| Last Update Date | 2023-01-19 |