| NPI | 1003000753 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR 153509) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AK 664) |
| Enumeration Date | 2007-09-05 |
| Last Update Date | 2011-01-22 |