| NPI | 1104880319 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: MA 402) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA 402) |
| 363AM0700X Physician Assistant Medical | |
| Enumeration Date | 2006-04-14 |
| Last Update Date | 2018-09-26 |