| NPI | 1053498279 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA052799) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA002194) |
| Enumeration Date | 2006-11-01 |
| Last Update Date | 2007-07-10 |