| NPI | 1053654814 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C05998) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110004213) |
| Enumeration Date | 2013-03-30 |
| Last Update Date | 2016-02-29 |