| NPI | 1972516318 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA1241) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MA 1241) |
| Enumeration Date | 2006-08-15 |
| Last Update Date | 2022-10-21 |