| NPI | 1912933532 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 4966) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: AZ 5823) |
| Enumeration Date | 2006-06-24 |
| Last Update Date | 2022-07-21 |