| NPI | 1083655153 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C03147) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: HI AMD-322) |
| Enumeration Date | 2006-06-09 |
| Last Update Date | 2010-02-17 |