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 |