| NPI | 1114128188 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: AL PA989) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TN PA0621) |
| Enumeration Date | 2007-05-29 |
| Last Update Date | 2015-08-17 |