| NPI | 1891104923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA058082) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: PA MA058082) |
| Enumeration Date | 2014-08-02 |
| Last Update Date | 2016-07-20 |