| NPI | 1114201076 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA060206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0001257) |
| Enumeration Date | 2011-10-10 |
| Last Update Date | 2018-10-04 |