| NPI | 1053321513 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: GA 003709) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 003709) |
| Enumeration Date | 2006-08-08 |
| Last Update Date | 2014-05-29 |