| NPI | 1023071990 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: PA OA00970) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: PA MA050959) |
| Enumeration Date | 2006-04-10 |
| Last Update Date | 2013-07-01 |