| NPI | 1104148386 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06922) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 006429) |
| 363A00000X Physician Assistant (Licence: NV PA1644) | |
| Enumeration Date | 2010-02-16 |
| Last Update Date | 2016-12-30 |