| NPI | 1912982638 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA052476) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-00045) |
| Enumeration Date | 2005-12-14 |
| Last Update Date | 2022-09-23 |