| NPI | 1033147962 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-00851) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C02769) |
| Enumeration Date | 2006-06-29 |
| Last Update Date | 2007-08-08 |