| NPI | 1982632618 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA055028) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9101857) |
| Enumeration Date | 2006-06-29 |
| Last Update Date | 2020-08-11 |