| NPI | 1104923986 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110002282) |
| Additional Taxonomies | 207P00000X Emergency Medicine (Licence: VA 0110002282) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2008-05-20 |