| NPI | 1114158565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA053990) |
| 363A00000X Physician Assistant (Licence: PA OA002381) | |
| Enumeration Date | 2009-08-03 |
| Last Update Date | 2009-12-01 |