| NPI | 1942640461 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SD 0872) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 53405) |
| Enumeration Date | 2013-06-28 |
| Last Update Date | 2017-11-16 |