| NPI | 1972597136 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2013028988) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 003793) |
| 363AM0700X Physician Assistant, Medical (Licence: GA 003793) | |
| 363AS0400X Physician Assistant, Surgical (Licence: GA 003793) | |
| Enumeration Date | 2005-09-02 |
| Last Update Date | 2014-05-27 |