| NPI | 1053314419 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: LA PA200020) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: LA A30284) |
| Enumeration Date | 2005-05-31 |
| Last Update Date | 2008-04-30 |