| NPI | 1104808187 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MT 337) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WY 311) |
| Enumeration Date | 2005-11-16 |
| Last Update Date | 2012-02-14 |