NPI | 1104117431 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA pa4149) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI pa00579) |
Enumeration Date | 2011-04-20 |
Last Update Date | 2015-11-11 |