| NPI | 1962874503 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0005944) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA060170) |
| Enumeration Date | 2015-10-22 |
| Last Update Date | 2018-10-29 |