| NPI | 1942586490 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA056244) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 5038) |
| Enumeration Date | 2011-10-28 |
| Last Update Date | 2020-12-18 |