| NPI | 1992132997 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-04542) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 2690) |
| Enumeration Date | 2013-10-04 |
| Last Update Date | 2017-06-06 |