| NPI | 1992956353 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 10381) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AK 2211) |
| 363A00000X Physician Assistant (Licence: CO 2684) | |
| 363A00000X Physician Assistant (Licence: NH 1031) | |
| Enumeration Date | 2008-10-03 |
| Last Update Date | 2021-11-02 |