| NPI | 1033391396 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-816) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-01031) |
| 363A00000X Physician Assistant (Licence: OR PA01464) | |
| Enumeration Date | 2007-11-28 |
| Last Update Date | 2012-10-23 |