| NPI | 1104096429 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MO 2011035886) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AR PA-461) |
| 363AM0700X Physician Assistant, Medical (Licence: VA 0110002717) | |
| Enumeration Date | 2008-03-03 |
| Last Update Date | 2018-08-29 |