| NPI | 1982942850 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C06362) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 006710) |
| 363AM0700X Physician Assistant, Medical (Licence: MD C0006362) | |
| 363AM0700X Physician Assistant, Medical (Licence: GA 006710) | |
| Enumeration Date | 2013-01-28 |
| Last Update Date | 2023-01-25 |