| NPI | 1003830233 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA056130) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 6126) |
| 363A00000X Physician Assistant (Licence: NC 0010-00510) | |
| Enumeration Date | 2006-07-27 |
| Last Update Date | 2015-12-17 |