| NPI | 1942296082 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-00509) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MD C0002314) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 0010-00509) | |
| Enumeration Date | 2005-09-23 |
| Last Update Date | 2024-06-10 |