| NPI | 1952472482 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2017032847) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 106246-1206) |
| 363AM0700X Physician Assistant, Medical (Licence: AZ 3726) | |
| Enumeration Date | 2006-11-13 |
| Last Update Date | 2023-02-02 |