| NPI | 1063771160 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MD C0004743) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA055471) |
| Enumeration Date | 2012-05-09 |
| Last Update Date | 2012-05-09 |