| NPI | 1023297546 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06623) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA 2429) |
| Enumeration Date | 2007-11-01 |
| Last Update Date | 2016-09-23 |