| NPI | 1972550192 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 9219) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT 100369) |
| 363AM0700X Physician Assistant, Medical (Licence: AK PADA547) | |
| Enumeration Date | 2006-05-31 |
| Last Update Date | 2022-08-12 |