| NPI | 1073534889 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SD 0721) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 109464) |
| Enumeration Date | 2006-07-21 |
| Last Update Date | 2009-11-05 |