| NPI | 1932411832 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2012001746) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 002123) |
| Enumeration Date | 2010-07-08 |
| Last Update Date | 2022-10-05 |