| NPI | 1013152008 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA053768) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA000708) |
| Enumeration Date | 2008-12-05 |
| Last Update Date | 2011-10-31 |