| NPI | 1912214602 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DC PA030692) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0004240) |
| Enumeration Date | 2010-09-02 |
| Last Update Date | 2018-02-16 |