| NPI | 1992796189 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: LA A10327) |
| Additional Taxonomies | 183500000X Pharmacist (Licence: LA pst.015227) |
| 363A00000X Physician Assistant (Licence: LA A10327) | |
| 363AM0700X Physician Assistant, Medical (Licence: LA A10327.RX) | |
| Enumeration Date | 2005-11-04 |
| Last Update Date | 2019-07-10 |