| NPI | 1013987312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MT 469) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: ID PA-577) |
| Enumeration Date | 2006-01-26 |
| Last Update Date | 2007-11-06 |