| NPI | 1073569224 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-00519) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: GA 004563) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 0010-0869) | |
| Enumeration Date | 2006-05-26 |
| Last Update Date | 2012-05-01 |