| NPI | 1003114067 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-02652) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 1623) |
| Enumeration Date | 2011-03-01 |
| Last Update Date | 2011-08-23 |