| NPI | 1063659910 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-01217) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NC 0010-02127) |
| Enumeration Date | 2009-01-14 |
| Last Update Date | 2016-11-28 |