| NPI | 1952664799 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110009144) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MD C04779) |
| Enumeration Date | 2012-06-18 |
| Last Update Date | 2023-08-09 |