| NPI | 1073555496 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA051968) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0000467) |
| Enumeration Date | 2006-06-11 |
| Last Update Date | 2014-12-23 |