| NPI | 1922356260 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA 60672189) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 015886) |
| 363A00000X Physician Assistant (Licence: MD C06755) | |
| Enumeration Date | 2012-08-16 |
| Last Update Date | 2024-02-28 |