| NPI | 1104875533 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 1940) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 1030432) |
| Enumeration Date | 2006-05-10 |
| Last Update Date | 2007-07-08 |