| NPI | 1003898107 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 001000486) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VA 110001306) |
| Enumeration Date | 2005-11-16 |
| Last Update Date | 2010-01-13 |