| NPI | 1063491025 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: SC 1634) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: 1053609) |
| Enumeration Date | 2006-01-10 |
| Last Update Date | 2011-10-11 |