| NPI | 1912998782 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA000807) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA051143) |
| Enumeration Date | 2005-11-02 |
| Last Update Date | 2021-02-15 |