| NPI | 1104023498 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 1550) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: GA 1550) |
| Enumeration Date | 2007-06-29 |
| Last Update Date | 2014-02-21 |